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�ETHICAL FOUNDATIONS
BRIEFING BOOK
WORKING GROUP # 17
�FOR OFFICIAL USE ONLY
ETHICAL FOUNDATIONS BRIEFING BOOK
TABLE OF CONTENTS
I.
BACKGROUND
II.
ISSUES
III.
RECOMMENDATIONS
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
Universal Access
Comprehensive Benefits
Equal Benefits
Fair Burdens
Generational Solidarity
Wise Allocation
Effective Treatment
Quality Care
Efficient Management
Individual Choice
Personal Responsibility
Professional Integrity
Fair Procedures
IV.
QUESTIONS AND ANSWERS
V.
APPENDIX
IA. Ethical Foundations of the New Health Care System:
Briefing Paper
AUTHORS: Dan W. Brock, Ph.D. and Norman Daniels, Ph.D.
IB.
The Preamble
Section I. For the public
Section 2. For policy discussions
2.
Privacy and Security of Health Care Information
3.
The Physician-Patient Relationship
4.
Bach, Marilyn, et al. "Ethics and Medicaid: A New Look At An Old
Problem."
5.
Baily, Mary Ann, "Rationing Medical Care"
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6.
Brock, Dan W., "The Problem of Low Benefit/High Cost Health Care"
7.
Brock, Dan W., "Medicine and Business: An Unhealthy Mix?"
8.
Buchanan, Allen, "Justice: A Philosophical Review"
9.
Daniels, Norman, " Insurability and HIV Epidemic: Ethical Issues in
Underwriting"
10.
Daniels, Norman, "Is the Oregon Rationing Plan Fair?"
11.
Daniels, Norman, "Justice and Health Care"
12.
Daniels, Norman, "Why Saying No to Patients in the United States Is So
Hard."
13.
Garland, Michael, "Justice, Politics, and Community: Expanding Access
and Rationing Health Services To Oregon"
14.
Morreim, E. Haavi, "Fiscal Security and the Inevitability of Bedside
Budget Balance"
15.
President's Commission for the Study of Ethical Problems in Medicine
and Biomedical and Behavioral Research: Recommendations.
16.
Welch, H. Gilbert, "Should the Health Care Forest Be Selectively Thinned
By Physicians or Clear Cut By Payers?"
17.
Wikler, Daniel, "Personal Responsibility for Illness"
18.
Priester, Reinhard, "A Values-Framework for Health Reform"
19.
Priester, Reinhard and Caplan, Arthur, "Ethics, Cost Containment, and
the Allocation of Scarce Resources"
20.
Caplan, Arthur and Priester, "For Better or Worse? The Moral and Policy
Lessons of Minnesota's Healthright Legislation"
21.
President's Commission on Ethical Problems in Medicine: Chapter 1
22.
ETHICAL FOUNDATIONS WORKING GROUP MEMBERS
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I. BACKGROUND
A. THE MORAL IMPORTANCE OF HEALTH CARE
Attention to ethical issues in the new systemreflectsawareness and commitment to
tbe moral traditions of our nation which are grounded in concern for equality, justice,
liberty, and community.
The central values/principles of equality, justice, liberty and community should be
applicable in all aspects of our lives. They are significantrelativeto health status because
they affect so many of us in very basic and fundamental ways. Inequalities in the health care
system at either levels of access or delivery seriously undermine our capacity to achieve a
just and caring community.
Health care is considered of fundamental moral importance in that it protects the
opportunities open to us to pursue our life goals, reduce our pain and suffering, prevent
premature loss of life, etc. These moral ideals also serve to affirm our values as members of
this society.
The health of a nation is a measure of its greatness. Preventable diseases, untreated
illness, and neglected disabilities tear at the fabric of society. The well being and sense of
security of the citizenry depends upon an effective health care system. When individuals
lack care, the promise of our common life together is diminished.
Our current health system violates many of the principles of equality, justice,
liberty, and community which undergird our nation. It does not provide security for the
people. It does not offer sufficient primary, preventative, mental health, or long-term care.
There are too many specialists. People are burdened with excessive costs. Prices for
medications are exorbitant. Vast numbers of people are uninsured or in jeopardy of losing
insurance. Generations are artificially pitted against generation in a competition for resources.
We acknowledge health care as not the only social good. We recognize, therefore,
the necessity of "trade-offs" and compromises. We accept the conditions of limits and
scarcity and observe that justice demands wise allocation and prudentresourcemanagement.
Health Care Reform should see that care is delivered to all, and that it will secure
and enhance life, liberty, and welfare. We must commit ourselves to universal and
comprehensive health care as a way to fulfill our national promise to all of our people.
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B. ETHICS AND PUBLIC POLICY ANALYSIS
"The distinction between ethical issues and those that are purely matters of policy
makes sense only after a great deal of ethical analysis has been successfully completed."
(Buchanan, Allen and Brock, Dan W. DECIDING FOR OTHERS: THE ETHICS OF
SURROGATE DECISION MAKING Cambridge University Press, 1989, p.5-6). We must
attempt to delineate the scope and limits of our ethical obligations to provide health care. In
addressing ethics and health care reform, we have made every effort to see that fundamental
ethical issues are not overlooked or ethical analysis function solely as a reaction to policy
rather than as a vital component of policy analysis and formation.
Ethical analysis is not restricted to social policy. "It examines problems of
individual ethical choice ....and takes as one of its tasks the problem of demarcating the
proper boundary between matters of individual choice and responsibility, and those of
collective responsibility and social policy" (Buchanan, p.5-6).
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n. ISSUES
PRINCIPLES AND VALUES WILL CONFLICT DUE TO DIFFERENCES
BETWEEN PEOPLE PHILOSOPHICALLY, CULTURALLY, RELIGIOUSLY,
AND POLITICALLY.
Ethical "trade-offs" are necessary in the development and implementation of Health
Care Reform. Examples are among the following:
•
PHASE-IN OF UNIVERSAL ACCESS
Although a phase-in might be politically and/or economically feasible, it may
compromise the principle of justice and its demands.
•
•
•
See Tab 4. Bach, Marilyn,"Ethics and Medicaid"
See Tab 21 . President's Commission on Ethical Problems in Medicine
EQUALITY
To ensure that competing health plans do not produce an unacceptable tiering,
specific steps are necessary at both the federal and state levels. These steps
may restrict choice in favor of equality.
•
See Tab 9. Daniels, Norman, Insurability and HTV
Epidemic"
•
See Tab 10. Daniels, Norman, " Is the Oregon Rationing Plan Fair?"
•
See Tab 11. Daniels, Norman, " Justice and Health Care"
COMPREHENSIVE BENEFITS VS. WISE ALLOCATION
The more comprehensive the package, the less likely the realization of cost
savings. The dilemma faced is in the concern for quality and fair distribution of
burdens.
•
See Tab 13. Garland, Michael, "Justice, Politics and Community..."
•
See Tab 9. Daniels, Norman, "Insurability and the HIV Epidemic"
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•
See Tab 14. Morreim, E. Haavi, "Fiscal Security and the Inevitability
of Bedside Budget Balancing"
INDIVIDUAL CHOICE VS. WISE ALLOCATION
It is not possible to have unlimited individual choice if we axe to fulfill our
responsibility to wise allocation. The new system should allow for a range of
more effective choices.
•
See Tab 5. Baily, Mary Ann, "Rationing Medical Care"
•
See Tab 12. Daniels, Norman, "Why Saying No to Patients in the
United States is so Hard"
•
See Tab 19. Caplan and Priester, " Ethics, Cost Containment, and the
Allocation of Scarce Resources"
•
See Tab 16. Welch, H. Gilbert, "Should the Health Care Forest be
Selectively Thinned...."
•
See Tab 17. Wikler.Dan, "Personal Responsibility for Illness"
GENERATIONAL SOLIDARITY VS. INDIVIDUAL CHOICE
As people age, they can pass through the system at step stages of life and thus
have a common stake in meeting our needs at each stage. Emphasis on
individual rights only reinforces an "us" vs. "them" view that conflicts with
solidarity across the community and across generations.
•
See Section V, Questions and Answers, #4
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HI. RECOMMENDATIONS AND RATIONALE
A. UNIVERSAL ACCESS
•
Recommendation:
Universal access is the soul of reform. Access for all citizens is essential.
Such access should not depend upon job status, ability to pay, prior medical
background, race, age, genetic background, sexual preference, disability,
geographical location, etc.
•
Rationale:
Justice is most efficiently served by creating appropriate security for America's
citizens. Having health care available to all serves to affirm our moral status as
full members of society and the moral community. We must remove the
barriers to access arising from linguistic and cultural differences, geographical
distance, prejudice, residence in economically deprived or underserved areas.
Access to Health care is a necessary condition to pursue nearly all of the goals
around which people organize their lives.
B. COMPREHENSIVE BENEFITS
•
Recommendation:
All plans should offer a comprehensive package of benefits, acceptable to
the majority of Americans and should be inclusive of primary care,
preventative, chronic, and long term care.
•
Rationale:
A comprehensive package for all will serve the interests of justice and equity.
This recommendation attempts to meet the needs of the people. We cannot
assure equality of opportunity without ensuring that this principle is satisfied.
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C. EQUAL BENEFITS
•
Recommendation:
The benefits package should be standardized acrosss plans. The quality and
availability of Health Care services should reflect only differences in our health
care needs, not other individual or group differences.
Rationale:
The principle of equality would dictate that the new health care system must
not continue or create two or more tiers of care. By their very definition, tiers
of care have been unequal and unfair. In order to avoid violation of this
principle, the quality of care to all must be comparable. Equality of
opportunity is acknowledged as a moral right.
Fair treatment in the access to benefits requires that the distribution of basic
social goods reflect only morally relevant, non-arbitrary differences between
people.
D. FAIR BURDENS
•
Recommendation:
The costs of meeting needs created by the health care system should be
spread equitably across the entire community. A community rating is
necessary. Ability to pay is to be factored in. Taxes and other financing
mechanisms must be progressive. The poor must be subsidized.
Rationale:
Adherence to the principles of justice and equality come into play here.
Differences in our risks of becoming ill and in the costs of meeting our needs
are largely underserved and beyond our control. Protecting equality of
opportunity is a shared obligation. Fairness requires spreading the costs of
insurance across the entire community. What we pay for health care should be
based upon what we are able to pay. Fair or just treatment of individuals
involves the distribution of burdens as well as benefits.
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E. GENERATIONAL SOLIDARITY
•
Recommendation:
We must share the benefits and burdens of the health care system fairly
across the generations.
Rationale:
We all have a common stake in a health care system that meets our needs.
The values of social solidarity and a communitarian ethic prevail here. Our
children and their children must come to understand their responsibility to
others. We cannot assure equality of opportunity without ensuring that this
principle is satisfied. A common health care system that serves and cares for
us will also bind us together in a broader national community.
F. WISE ALLOCATION
•
Recommendation:
We must limit the growth of health care expenditures. We must balance
what we spend on health care with other national priorities.
Rationale:
A central value of health care is its preservation of our opportunities to pursue
the other things we care about in life. If we can limit the growth of our health
care expenditures, we will be in a better position to meet our other needs.
Since we do not value all health care services equally, we must give priority to
services that meet our most important needs.
G. EFFECTIVE TREATMENT
•
Recommendation:
We support "outcomes" research and research that can lead to new
treatments in order to assess effectiveness of various services and benefits.
Rationale:
Limited data and perverse incentives to over-utilize services lead to use of
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unnecessary care that does not benefit patients. We support expansion of
services beyond acute care and new technologies which are beneficial and
warrant any additional costs.
H. QUALITY CARE
•
Recommendation:
New quality measures must be developed to ensure that quality is
maintained for individuals and for the system. Effective grievance systems
must be developed. Unethical and incompetent practitioners must be weeded
out.
Rationale:
The new system should strive to eliminate waste and yet not compromise
quality of care to those who need it. In the interests of caring for all and
making the system work, mechanisms must be put in place to assure quality at
all levels.
I. EFFICIENT MANAGEMENT
•
Recommendation:
The health care system must be organized simply and minimize
administrative costs.
Rationale:
Such organization will be less wasteful and will not interfere with quality care
or divert resources from effective delivery of services to those in need.
Administrative burdens should not be added to the burdens of illness or
disability. Providers do not need administrative burdens which interfere with
appropriate patient care.
J . INDIVIDUAL CHOICE
•
Recommendation:
The system must allow and respect reasonable patient and provider choice
which encourages personal responsibility, protects professional integrity, and
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IV. QUESTIONS AND ANSWERS
1.
Is health care a good of special moral importance? Do we have rights to
healthcare?
Allen Buchanan, in Justice: A Philosophical Review, suggests how different theories of
justice ( egalitarian, libertarian, utilitarian) might approach the distribution of health care.
Libertarian views argue for a minimalist view of the state and leave little room for
redistributing wealth to make health care available to all. Utilitarian views can support a
decent basic minimum of health care, but they make individual claims on health care depend
very much on how the health care system promotes aggregate well-being in society;
individuals can be left quite vulnerable.
In Just Health Care and his overview paper, Justice and Health Care, Norman Daniels
argues that health care is of fundamental moral importance because of its ability to protect
equality of opportunity. Disease and disability shrink the range of opportunities open to
people; health care protects that range. Rights to health care become a special case of rights
to equality of opportunity. Though health care is of special moral importance, it is comparable
to education, which also protects equality of opportunity; it is not the only important good
and reasonable resource limits must be placed on what we spend on health care. The view
supports universal access, the provision of comprehensive health care benefits whose
importance is judged by their efficacy in addressing needs, and limitations on benefits as a
result of resource limitations only if they are fairly applied to everyone and publicly justified.
This book has been influential in Canada, the Netherlands, Norway, Denmark, and elsewhere,
where government commissions have been thinking about health care reforms under budget
constraints.
Ezekiel Emmmanuel's The Ends of Human Life articulates a communitarian approach
to health care distribution, arguing that basic choices about the distribution of health care
require choices made by small communities that share fundamental values. He argues that
liberal theory cannot answer these questions about the goals of medicine. Other
communitarian approaches to health care are reflected in works by Daniel Callahan, author of
Setting Limits: What Kind of Life?
An opposing view to the claim that health care is of special moral importance, an that
there are social obligations to provide it, can be found in libertarian works such as Tristram
Engelhardt's Foundations of Bioethics.
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The ethical discussion in the President's Commission Report On Securing Access to
Health Care (1983) grounds the special importance of health care in its effects on
opportunity, its role in reducing pain and suffering, and the information and assurance it
provides us. This language is reflected in the ethical principles which the Ethics Working
Group has provided.
2.
What ethical considerations affect decisions about benefits?
The "Ethical Foundations" paper argues that benefits must be comprehensive and that
the principle for distributing medical services must be responsive to medical need, not other
differences among individuals or groups It takes a strong stand against arbitrarily omitting or
reducing coverage for whole categories of services ( mental or preventive), and it takes a
strong stand against permitting unequal tiers of medical insurance that trap low income people
in low quality health plans.
There is strong support for these views in Just Health Care and in Daniels' Am I my
Parents' Keeper? Arbitrary categorical distinctions among kinds of services (preventive vs
curative, acute vs chronic or long term, mental vs physical, which have often influenced the
content of insurance benefit packages, have no moral standing and are arbitrary. Mental
health services, if they are effective and meet important needs, have the same impact on the
opportunities and welfare of individuals as physical health services, and should not be
discriminated against in benefit packages. Similarly, long term care services restore normal
function, prevent further losses of function, or compensate for losses of normal function, just
as do acute care services; they must not be given secondary status in thinking about benefits.
To our knowledge, there is no literature that argues an opposing view.
3.
Is health care insurance just like other kinds of insurance?
The marketing of private health care insurance in the United States has generally
behaved like all other insurance markets: standard underwriting practices are used to exclude
those at high risk from insurance and to risk-rate insurance groups. Insurers have even
argued that they are morally required to behave this way in order to market "actuarially fair"
insurance. Daniels' article on insurability uses the HTV epidemic to highlight what is morally
unacceptable about these practices. Because of the fundamental importance of health care,
the social function of health insurance, whether it is private or public, must assure access to
services.
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The Daniels article on exclusionary underwriting practices cites literature that offers an
opposing view. The main motivation for insurers, however, is not moral but economic, that
is, to protect themselves from adverse selection. The social costs of these exclusions are
unacceptable.
4.
How should the burdens of providing health care be shared?
Should those who are sick or at higher risk pay more for insurance? Daniels article
on HIV and insurability argues for community rating.
We have provided no literature specifically discussing the ethical issues involved in
more vs less progressive forms of financing. Both utilitarian and egalitarian approaches to
public policy would generally support more rather than less progressive financing: general
revenues rather than pay taxes, though payroll taxes could be supplemented by "health taxes"
on unearned income and taxes rather than premiums. Sin taxes are often regressive in their
effect, though they provide incentives to healthier behavior.
A key obstacle to sharing the burdens of financing health care fairly are divisions that
emerge between "us" and "them". The problem is particularly long term care, which is often
(incorrectly) seen as a problem of the young vs. the old. Since we all age, however, we have
a common stake in designing a health care system that meets our needs at each stage of life
and for sharing the economic burdens of doing so. Daniels elaborates this argument in A m i
my Parents' Keeper?, claiming that we treat people in different age groups fairly if we design
systems that involve prudent allocations across stages of life.
It is sometimes argued that those who engage in unhealthy lifestyle choices should
bear the burden of their choices, either by having to pay more for their health care or by
being denied some services. The "Ethical Foundations" paper rejects this position. Support
for its stance can be found in Wikler's paper on Coercion and Lifestyle Choices.
5.
How can we protect doctors and patients under pressure to contain costs?
When DRG's were introduced, American physicians began to complain loudly that
"bureaucrats" were interfering with appropriate clinical care. The theme is echoed in response
to micro management of clinicians by different insurance schemes. There is a growing
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literature on the ethics of these institutional pressures on clinicians and patients. Daniels' Why
Saying No Is So Hard in the United States is an early piece on this problem. It argues that
physicians must believe a system is fair and that their participation as gatekeepers works to
the advantage of patients overall before their inclination to "game" the system can be reduced.
Where incentives work to make providers offer less treatment, the incentives should not
directly impact on the physicians, but should be spread through larger groups of providers.
The Ethical Foundations policy paper argues for establishing grievance procedures
within health plans and health alliances so that doctors and patients can oppose what they
take to be unreasonable or unfair constraints on treatment. Time has prevented us from
gathering supporting literature on such procedures, but the detailed Guidelines produced by
the Ethics Working Group cover many of these issues.
�RECOMMENDED READING
Callahan, Daniel. Setting Limits: What Kind of Life.
New York: Simon and Schuster, 1990.
Daniels, Norman. Am I my Parents' Keeper? New YorK: Oxford Press, 1988.
Daniels, Norman. Just Health Care. Cambridge: Cambridge Press,
1985.
Emmanuel, Ezekiel. The Ends of Human Life.
Engelhardt, Tristram. Foundations of Bioethics.
Reich, Warren, Editor. The Encyclopedia of Bioethics.
The President's Commission for the Study of Ethical Problems in Medicine and Biomedical
and Behavioral Research, Vol 1-4. Securing Access to Healthcare. 1983
Flack, Harley and Pellegrino, Edmund. African American Perspectives on Biomedical
Ethics. Washington, D.C. Georgetown University Press.
�V. APPENDIX
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ETHICAL FOUNDATIONS OF THE NEW HEALTH CARE SYSTEM
The design of our new health care system is shaped by basic moral principles and values
that are widely shared in our society. In the first section of this paper, we articulate fourteen
principles and values that guide policy decisions and choices about central features of the new
health care system. These principles and values are not pulled from thin air or selected simply
to conform to the new system. Instead, they are deeply anchored in the moral traditions we share
as a nation, reflecting our long standing commitments to equality, justice, liberty, and community.
Different moral, religious, and cultural traditions within our society may emphasize different
elements among these principles and values or give them different weight when they conflict.
Nevertheless, there is a widespread consensus on them and on their central role in defining our
common community, as we show in the second section of this paper.
These principles and values will conflict in various ways, and trade-offs among them
must be made in designing a health care system. People may disagree about just how these
tradeoffs should be made, reflecting both different philosophical, cultural, and religious traditions,
as well as different values we affirm as individuals. In the third section, we discuss some
important tradeoffs that arise in key choices about the design of the system and show how the
principles illuminate what is at stake in these decisions. These trade-offs occur not only among
the principles and values, but with judgments of what is politically feasible as well.
SECTION I: ETHICAL PRINCIPLES AND VALUES OF THE NEW HEALTH CARE
SYSTEM
Although we tolerate many inequalities between people in our society, the great
inequalities that have arisen in access to health care services seriously undermine our
achievement of a just and caring community. Because health care is so important, access to it
should not depend on the contingencies of our job status or our ability to pay, our prior medical
history or where we happen to live. We can explain this importance by considering the profound
effects health care can have on our lives:
THE FUNDAMENTAL MORAL IMPORTANCE OF HEALTH CARE. Health care
is of fundamental moral importance because it protects the opportunities open to us to
pursue our goals in life, reduces our pain and suffering, prevents premature loss of life,
and gives us information we need to plan our lives.
This statement of the value of health care displays the diverse benefits it provides us. For
example, reducing pain and suffering, preventing the premature loss of life, and providing
information are all among the ways in which health care protects the range of opportunities open
to us. Health care services protect our opportunities in various ways: some services prevent
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disease and disability and help us to maintain our health; others cure disease and repair the
effects of injury; others compensate for losses of function and capability; still others keep us from
losing further function. In reducing pain and suffering, and in preserving our lives, health care
also directly serves our well-being. Having health care available to us also importantly serves
to affirm our moral status as full members of society and the moral community.
CARING FOR A L L
Because health care is a fundamental good, the moral ideals of justice, equality, and
community require that the health care system be universal, comprehensive, and equitable in the
sharing of benefits and costs.
UNIVERSAL ACCESS: Everyone must have access to health care services without financial
or other barriers.
Increasingly, Americans, whether insured or uninsured, fear that they will be unable to
obtain needed health care. We must provide a new security that appropriate health care services
will be available to all Americans, making health care a right, not a privilege. No one should fear
that a change or loss of a job, part-time or temporary employment, or economic plight will
deprive them of health care coverage. No one should lose access to health insurance or be denied
coverage for needed services due to pre-existing conditions, age, race, genetic background, or
disability. We must remove the barriers to access arising from linguistic and cultural differences,
geographical distance, prejudice, residence in economically deprived or underserved areas, or
From excessive out-of-qocket qavments. The qrinciqle of universal access is the soul of the,
reform. Universal access can no longer be a distant ideal; we must offer it to all now.
COMPREHENSIVE BENEFITS: The health care system must meet the full range of our health
care needs.
All health insurance plans should offer a comprehensive package of benefits that will be
acceptable to the vast majority of Americans. Entire categories of health care services should no
longer be excluded from coverage without regard to their benefits in meeting needs. Since
meeting needs is what gives health care its special importance, any limitations in coverage should
be of those services that provide the least benefits to patients relative to their costs. Health
insurance plans should cover primary, preventive, chronic and long-term care, as well as acute
care; home, as well as hospital care; treatment for mental as well as physical, illness.
EQUAL BENEFITS: Health care services should reflect only differences in our health care
needs, not other individual or group differences.
The system must not create two or more tiers among citizens, dividing the nation over
these fundamental services, and leaving the worst-off among us with lower quality and more
restricted services. Ability to pay should not give some people access to important medical
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services that others cannot afford. Health care differs even from other important goods like
housing. Modest housing will suffice for shelter, but diminished health care services can
profoundly limit our opportunities, result in preventable pain and suffering, and even cost us our
lives. Providers should not have to determine patients' insurance coverage before offering needed
care.
FAIR BURDENS: We should spread the uneven costs and burdens of meeting our health care
needs across the entire community; our payments for health care should be based on ability to
pay.
The astronomical costs of health care can impoverish the sick and disabled and their
families, compounding the burdens of illness with the prospect of financial ruin. Because
differences in our risks of becoming ill and in the costs of meeting our needs are largely
undeserved and beyond our control, and because protecting equality of opportunity is a shared
obligation, fairness requires spreading the costs of insurance across the entire community.
Individuals' insurance premiums should be "community rated." In addition, all must belong to the
health care system and share in its support—individuals should not be able to free ride on the
sacrifices of others to support health care costs. Even when well, we all share the risk of
becoming sick; the well should share the costs of treating the sick. How likely we are to be sick
or to stay well should not determine how much we pay for our health care.
We pay for health care in various ways—through taxes, insurance premiums, and
co-payments for services—and these should be based on people's ability to pay. This means that
taxes and other financing mechanisms must be progressive, with high income individuals paying
more and that premiums and co-payments of the poor must be subsidized by the government.
GENERATIONAL SOLIDARITY: The health care system must respond to our needs at each
stage of our lives, and we must share its benefits and burdens fairly across generations.
We commonly perceive that the needs of the old and the young are in conflict. We must
renounce this "us" versus "them" mentality that pits generations against each other. We all age
and have a common stake in a health care system that meets our needs as they change throughout
our lives. By providing for these needs and sharing the burdens fairly, the new health care system
can give us all a new security that our needs, and the needs of our family members and those
we care for, will be met throughout our lives.
MAKING THE SYSTEM WORK
In order to most effectively meet our health care needs without sacrificing other important
goals, the new health care system must allocate wisely, treat effectively, ensure quality, and
manage efficiently. Controlling costs without compromising quality is a moral, not just economic,
imperative: it is the way we achieve the most good for people with limited resources.
WISE ALLOCATION: The nation must balance wisely what we spend on health care with
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other national priorities, as well as allocate resources within health care to services that meet our
most important needs.
We do not value health care alone. We must also educate our children, provide housing,
and defend our nation. A central value of health care is its preservation of our opportunities to
pursue the other things we care about in life, and so resources must be available for these other
activities as well as for health care. In the past, the organization and funding of the health care
system has not enabled us to make clear choices among these priorities. By limiting the growth
of overall health care expenditures, we will be in a better position to meet our other social needs.
Likewise, we do not value all health care services equally and so must give priority to services
that meet our most important needs.
EFFECTIVE TREATMENT: We must deliver effective services, avoid ineffective ones, and
support research that leads to new treatments that work.
Limited data about the effectiveness of many commonly used treatments, as well as a
variety of perverse incentives to over-utilize services, lead to use of unnecessary care that does
not benefit patients. We must not waste our health care resources on treatments that do not work.
We must increase substantially our support for "outcomes" research to leam what benefits
different treatments provide. We must expand our research on the outcomes of health care to the
broader range of services the system must offer, not just acute care. We must evaluate whether
new technology produces benefits that warrant its additional costs.
QUALITY CARE: We must ensure that high quality services are available and that individuals
receive the information necessary to make informed health care choices.
Our new system must strive to eliminate waste and deliver services efficiently, but we
must not allow it to compromise the high quality we expect when our health is at stake. New
quality measures must be developed that ensure quality is maintained in individual treatments and
in health care delivery systems, without creating excessive administrative burdens. Effective
grievance systems must be developed for patients who believe the quality of their care has been
compromised. Assuring quality requires an environment that fosters the best work of health care
professionals and weeds out unethical or incompetent practitioners.
EFFICIENT MANAGMENT: The health care system should be simply organized, easy to use
for patients and professionals, and should minimize administrative costs.
The administration of our health care system is now unnecessarily complex and wasteful.
We use a higher proportion of our health care expenditures for administrative costs than any
other country—this interferes with quality care and diverts resources from the delivery of
effective services. Patients and families must not have the burdens of unnecessary paperwork
added to the burdens of illness. Providers must no longer face the administrative burdens imposed
by insurers whose micro management of clinical decisions often interferes with appropriate
patient care.
CHOICE AND RESPONSIBILITY
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The new health care system must respect the choices appropriately left to patients or
providers, encourage personal responsibility and protect professional integrity, while ensuring
accountability through fair procedures.
INDIVIDUAL CHOICE: The health care system should enable all of us to make effective and
informed choices about our providers, health care plans, and the treatments we receive.
Since health care has such profound effects on people's lives, we must respect personal
choice in the health care system. Individuals should be able to maintain important existing
relationships with providers. They should be able to choose the type of health care plan to which
they belong. Within their health care plans, they should be able to choose health care
professionals with whom they can work compatibly and to have their choices about treatment
respected. Consumers and patients should be provided with adequate information and counsel so
that all of their choices will reflect their particular needs and values. Honoring choice in the
health care system not only respects liberty and individual self-determination, but also engages
patients in the success of their treatment.
PERSONAL RESPONSIBILITY: The health care system should help us take responsibility for
protecting and promoting our health and the health of our families.
Much of what we do affects our health. The health care system should provide
information, education, counseling, and treatment that empower us to make effective choices
about how to protect our health. It is also appropriate for society to create incentives for
individuals to reduce unhealthy behaviors, such as taxes on cigarettes and alcohol, and to ensure
treatment programs are available which help people change such behaviors. But access to needed
care should not be denied because health care needs may be caused by unhealthy behaviors.
Making the connection between individual patient behavior and disease would often be too
difficult and too intrusive. Neither patients nor providers would want the provision of care to
have to await determination of responsibility.
PROFESSIONAL INTEGRITY: The health care system must respect the clinical judgments
of professionals and protect the integrity of the professional-patient relationship, while ensuring
that the profession fulfills its public responsibilities.
All of us have a stake in ensuring that the integrity of the professional-patient relationship
is protected and preserved. Efforts to control the growth of health care costs must not be
permitted to undermine either the commitment of professionals to the well-being of their patients
or the trust of patients in that commitment. The health care system must contain procedures for
appeal by either professionals or patients when they believe the integrity of their
professional-patient relationship is threatened.
A huge social investment has helped to form and educate health care professionals. The
health care system should foster ways in which professionals can give back to their community,
for example through national service or work in underserved areas.
FAIR PROCEDURES: To protect these principles and values, fair and open democratic
procedures should exist for making decisions about the operation of the health care system and
for resolving disputes about individual patient care.
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Even in a just and caring society, reasonable people will disagree about how to translate
our moral ideals, principles and values into a well-functioning health care system. Difficult and
controversial trade-offs and decisions will have to be made. In a democracy that aspires to
respect all people and everyone must have access to the reasons for the decisions that may affect
them so profoundly and must have access to a fair procedure for resolving disputes.
SECTION II: FOUNDATIONS OF THE PRINCIPLES AND VALUES
Because this health care reform is a sweeping change that profoundly affects the lives of
all Americans, the principles and values that guide it must rest upon the moral ideals to which
our nation is dedicated. Our long held beliefs and our highest aspirations about justice, equality,
liberty, and community justify this undertaking. These ideals, like the specific health care
principles and values guiding the health care reform, will sometimes come into conflict, and no
one of these ideals must be pursued at the cost of all the others.
EQUALITY
Our nation was founded upon the belief that all individuals deserve equality of
opportunity to pursue their chosen goals in life. By providing health care to all, we move toward
the attainment of that ideal. Pain and suffering, disability and limitation of function, and
premature loss of life all restrict our opportunities. In recognition of the fundamental impact
education has on our opportunities, we long ago made a committment to a system of public
education available without charge to all members of our society. We thus acknowledge a moral
right to fair equality of opportunity. The language of rights expresses the strongest moral claims
of individuals against their fellows and their societies. In different ways, health care is at least
as important as education in securing equality of opportunity. While health care typically does
not open up new opportunities in the way education often does, without needed health care we
are often deprived of opportunities that would otherwise be open to us. Health is not a goal
around which we organize our lives, but a necessary condition for pursuing nearly all of the goals
around which people do organize their lives. It is in this respect a basic requirement of fair
equality of opportunity.
Several of the specific health care principles and values are given direct and strong
support by the concern for equality of opportunity. We could not assure equality of opportunity
without ensuring that the principles of UNIVERSAL ACCESS, COMPREHENSIVE
BENEFITS, EQUAL BENEFITS, and GENERATIONS STANDING TOGETHER are
satisfied. Other concerns about equality and just or fair treatment, such as the dignity and worth
of individuals, and the equal concern and respect each person is owed, also support these and
other of the principles. Ensuring that all our citizens have equal access to health care is a potent
means and symbol of the equal regard our society and our government should have for all our
citizens.
JUSTICE
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Our discussion of equality has already introduced some aspects of justice and the fair
treatment of individuals. Fair treatment in the access to benefits requires that the distribution of
basic social goods reflect only morally relevant, non-arbitrary differences between people. Health
care should be distributed in accordance with health care needs as the principle of EQUAL
BENEFITS requires. Philosophical theories of justice differ on many matters, including what
goods a society should secure for all its citizens as a matter of right. Nevertheless, nearly all
agree that it is a serious injustice when individuals suffer serious preventable loss of opportunity,
preventable pain and suffering, or even preventable loss of life for want of health care readily
available to most members of a country as rich as our own. And ordinary citizens too recognize
the simple injustice of the harms that come to individuals from want of even basic health care
services.
Fair or just treatment of individuals involves the distribution of burdens as well as
benefits. People disagree about how much inequality of income and wealth is fair or just. But
here too there is widespread agreement that justice requires the contributions of individuals to
basic public goods like education and the common defense be based on their ability to pay. Our
progressive federal income tax rates reflect this consensus. For health care too, which has come
to be an increasingly large component of individual and governmental budgets, individuals'
payments for health care, whether direct or indirect, should be based on their ability to pay.
Justice, and the principles of FAIR BURDENS and GENERATIONAL SOLIDARITY it
supports, obviously do not provide a precise formula for the financing of health care, but can
help guide the many detailed decisions about how the new system will be financed.
A further aspect of justice involves ensuring that health care does not exhaust resources
needed for other valuable activities, including other requirements of justice such as ensuring
adequate housing, nutrition, and education. This is directly addressed by the principle of WISE
ALLOCATION. The principles of EFFECTIVE TREATMENT, QUALITY CARE, and
EFFICIENT MANAGMENT indirectly serve justice: they ensure that health care needs are met
with high quality care while minimizing those uses of resources that fail to secure significant
benefits to patients. These four principles do not merely serve prudent allocation and economic
efficiency. They also serve justice by ensuring that other requirements of justice outside health
care can be met and serve the moral value of individual well-being and human flourishing by
maximizing the benefits people receive from limited health care resources.
Finally, justice or fairness also requires FAIR PROCEDURES to resolve the many
reasonable disagreements that will inevitably arise about the design and operation of the health
care system even among people in agreement about the principles and values that should guide
the system.
LIBERTY
Our revolution began over two centuries ago with a protest against overbearing
governmental authority. Our Constitution enshrines the value of personal choice and tolerance
of diversity. In health care there is a long legal tradition respecting individual liberty going back
at least to the early part of this century when Justice Cardozo, in the case of Schloendorff v.
Society of New York Hospital, held that: "Every human being of adult years and sound mind has
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a right to determine what shall be done to his body." The requirement that medical care not be
rendered without the free and informed consent of a competent patient is now deeply and firmly
embedded in professional practice and in our legal system.
Liberty cannot, however, be unlimited. Sometimes it is necessary to limit people's liberty
in order to prevent their causing harm to others. And sometimes it is necessary to limit people's
liberty in order to carry out desirable social purposes. But a commitment to the high value of
individual liberty implies that these other worthy purposes be carried out with minimal limitation
of liberty. It is not only the liberty of patients that is important in the health care system, but also
the liberty of providers necessary to maintain PROFESSIONAL INTEGRITY.
We recognize also that some liberties are more important to us than others. Choices that
affect our lives in far-reaching and deeply personal ways, such as whether and whom to marry
or what occupation to pursue, must not be taken from us. Health care too, or the lack of it,
affects us in far-reaching and deeply personal ways. When our lives, goals, and very existence
are threatened by illness and disease^ we are particularly concerned to control our fate. Thus, the
health care system must be designed to respect the principle of INDIVIDUAL CHOICE. A
proper concern for liberty recognizes that with liberty comes personal responsibility for our own
health. The principle of PERSONAL RESPONSIBILITY recognizes the health care system's
role in enabling and encouraging people to take responsibility for their own health, without
violating the principle of EQUAL BENEFITS by denying care when health care needs are
caused by unhealthy behavior.
COMMUNITY
We began our life as a nation with the proclamation "We the people," declaring our intent
to join together in a single national community. To further bind us together as one community
we must remove the division between those excluded from and included in the health care
system. We are members not only of a national community, but of many diverse, smaller
communities that flourish within our society: religious communities, ethnic communities, as well
as the neighborhoods, towns, and cities in which residents share a common life. Fundamental to
all of these different communities is a shared concern and responsibility for one's fellow
members, especially those suffering misfortune and in need of the help of others.
A health care system that serves the principles and values calls on and strengthens the
shared concern for our fellows thatflourishesin the many communities that make up our nation.
A common health care system that serves and cares for us all will also bind us together in a
broader national community.
We celebrate our diversity as a nation. Our many religious, ethnic, and cultural traditions
and groups are one of our great strengths: they show us the many ways we can lead a good life.
We also differ amongst ourselves about the full meaning and relative importance of the moral
ideals of equality, justice, liberty, and community that undergird the health care reform. These
differences will sometimes lead us to disagree about the appropriate trade-offs to be made among
the principles and values in designing the health care system. Despite our diverse origins, we
share a broad consensus and commitment as a nation to these ideals and to the principles and
values they support. With good will, tolerance and respect for our diversity, and a willingness
to compromise when we reasonably disagree, we can construct a health care system that is
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worthy of our moral ideals as a nation.
SECTION HI: ETHICAL CHOICES IN DESIGNING THE NEW SYSTEM
The principles and values we have described, as well as the underlying moral ideals that
support them, will conflict at many places in the design of the new system. In addition, people
will disagree about how the necessary trade-offs among them should be made. Not only do key
choices about the design of the system reflect conflicts of vaue, they also reflect different
judgments about what it is politically feasible to accomplish. Successful political reform must
avoid two moral errors: aiming too low, thereby missing the opportunity and need to secure
fundamental reform, and aiming too high, rejecting all reform that falls short of an ideal which
is not achievable. Aiming at the best achievable target is notoriously difficult because judgments
about political feasibility are very complex, involve much uncertainty, and because we also
disagree about what is ideal. In what follows, we analyze what is ethically at stake in ten key
choices about the design of the new system, showing how the principles and values are
embodied, where they conflict and require trade-offs, and where judgments of political feasibility
enter in.
THE PHASE-IN OF UNIVERSAL ACCESS
The failure to provide health care coverage for 37 million persons represents the single
most morally compelling reason to reform the health care system. Providing universal access to
health care services for all Americans without financial or non-financial barriers goes to the soul
of reform. Equality and justice require rapid and certain coverage for the uninsured. Universal
coverage must not depend on political and economic contingencies over an extended period of
time. It cannot await cost savings that the new system will produce.
Political feasibility as well as concern for other principles such as WISE ALLOCATION
might incline us to seek the fiscal and administrative advantages of a lengthy 5 to 7 year
phase-in period during which groups such as children, then employed and self-employed adults,
and finally Medicaid recipients would be folded gradually into the system. However, justice does
not permit the continued exclusion of Americans from our health care system. When we
recognized that guaranteeing equality before the law and due process of law required providing
legal representation for indigent defendants, we did so without an extended phase-in period.
When natural disasters like hurricanes leave people homeless, we provide them with needed aid
as quickly as possible. Though both efforts require new resources, the demands of justice and the
urgency of the needs oblige us to respond. It is the same with health care—the demands of
justice and the urgency of the needs of the uninsured require realizing UNIVERSAL ACCESS
without an extended phase-in to cushion the fiscal impact.
EQUALITY OVER TIME
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Together, the principles of UNIVERSAL ACCESS, EQUAL AND COMPREHENSIVE
BENEFITS, QUALITY CARE, and INDIVIDUAL CHOICE require the new health care
system to protect low-income and other vulnerable and underserved populations. They must have
access to health care plans whose benefits and quality are acceptable to the broad majority of
Americans. We must not recreate a two-tier system in which the lower quality tier—like
Medicaid—is a dumping ground for the poor. To ensure that competing health plans do not
produce unacceptable inequality, specific steps are necessary at both the federal and state levels.
Unacceptable inequality will exist if low-income individuals can only afford low cost
plans whose quality is unacceptable to everyone else. Higher cost health plans could have more
or better quality specialists and reduced waiting time for treatments. They could provide increased
benefits by introducing new technologies and treatments more quickly and visibly.
Some of these differences constitute only amenities that do not significantly affect health
outcomes. People should be able to buy them if they wish, but they do not warrant public
subsidy. Some other differences in quality, however, such as shorter waiting times, better
continuity of care, and more widespread use of beneficial new treatments can lead to differences
in health outcomes, consumer satisfaction, and the quality of the plan. The goal of offering the
same comprehensive benefits will then be undermined.
BALANCING INDIVIDUAL CHOICE WITH CONTROLLING COSTS
In policy design, as in our individual lives, it is not possible to have unlimited choice. In
order to protect some choices, as well as to pursue other values, it is necessary to limit or forgo
other choices. The moral task is to decide how to secure the choices we judge most important,
consistent with achieving other values. In the design of the health care system, most people are
principally concerned with three kinds of choices: choice of the type of health care plan in which
they will receive care; choice of physicians and other providers; choice of treatments they will
receive. The new health care system will increase most people's choices of kinds of health care
plans. Health Alliances will typically offer managed care plans together with at least one
traditional fee-for-service type plan from which people may choose; individuals will have the
choice to change plans annually. People will no longer be limited to the plan or plans their
employer happens to offer, and will not be forced to change plans when they change employment
or when their employer changes the plans offered. Because ALLOCATING WISELY and
MANAGING EFFICIENTLY, while ENSURING QUALITY, tend to be achieved at lower
costs by managed care than fee-for-service plans, there will be incentives, but no coercion, to
join them. Because all plans must offer a uniform comprehensive benefits package, along with
easily understood quality measures of their services, more effective comparisons and choices will
now be possible between alternative plans. Individuals who wish to purchase supplemental
insurance, or to pay out-of-pocket, for amenities or services not covered in the uniform benefits
package will be free to use their private funds to do so. This qualification of the EQUAL
BENEFITS principle is less morally troublesome than when the poorest Americans have access
to substantially less services than do most Americans, as at present.
Since many people are likely to switch from fee-for-service to managed care plans in the
new health care system, they may have more limited choice of physicians than at present.
Nevertheless, everyone will have substantial choice of physicians because health plans will be
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required to allow members to choose, and to change, physicians within the plan.
Finally, as we gain increased knowledge about what treatments work for what conditions,
patients will be able to make more informed choices of treatment altematives.Since the present
rate of growth in health care expenditures is not sustainable, even those people who are now
well-covered by health insurance are at risk of erosion or loss of that coverage and the choices
they now have if the system is not reformed. The new system will provide the security that
substantial choice will be protected for them and their families into the future. Finally, and of
great moral importance, those now substantially excluded from the health care system because
they lack any, or adequate, health insurance will now be brought into the system as full, equal
members. They will have new, effective choices at all levels—of health care plans, providers,
and treatments—that they are now usually denied.
PROTECTING PROFESSIONALS AGAINST EXCESSIVE COST CONTROL
PRESSURES
Controlling the growth of health care costs by ALLOCATING WISELY, MANAGING
EFFICIENTLY, AND TREATING EFFECTIVELY may create new and increased pressures
on providers to limit care which threaten PROFESSIONAL INTEGRITY. The new health care
system will likely speed the growth of managed care plans and reduce professionals' opportunities
for fee-for-service practice in which there have often been few limits on the treatments and
services that physicians could order and patients' insurance would pay for. Experience with
managed care systems has suggested that their ability to control costs depends upon the primary
physician or provider serving asfinancialgatekeeper.
Professionals can serve with integrity as a gatekeeper within a managed care system.
Primary care professionals have always accepted a commitment to all patients within the practice,
not merely to the patient present at the moment. And this broader commitment includes an
obligation to allocate wisely limited resources such as the professional's time. Properly
understood, and assuming an adequate pool of resources, the role of primary care provider
conflicts only minimally and occasionally with the role of the primary provider as patient
advocate. In general, the advocate role predominates when the resources will most clearly provide
a marked benefit to this particular patient; the gatekeeper role predominates when the benefit is
slight or uncertain.
A particular managed care system, however, might violate professional integrity by
sacrificing too many other values to the gatekeeper function. For example, financial incentives
to withhold beneficial treatment may intrude directly into the provider's clinical decision making,
thereby conflicting with ENSURING QUALITY, or the nature of the gatekeeper system and its
financial incentives may not be disclosed frankly to patients, as required by FAIR
PROCEDURES. Whether the values of patient advocacy and patient choice are being unduly
sacrificed to economic efficiency or the profit motive can be determined only by a detailed
inspection of the day-to-day practice patterns within a health plan. This reinforces the need for
ongoing ethics scrutiny within all health plans, and the need to see decisions about benefit
packages, patient appeals, etc. as having an important ethical component.
THE PROVIDER-PATIENT RELATIONSHIP
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For many people, maintaining a close long-standing relationship with a trusted primary
care provider is now, and will continue in the new health care system to be, of fundamental
importance. Having a provider who knows us and our needs and concerns well, and whom we
trust always to have our interests paramount in caring for us, is what gives us security that
appropriate care will be available to meet our future health care needs. For people with
disabilities or chronic illnesses, having a comparable specialist with whom one has dealt for many
years can be essential to securing necessary and appropriate health care services and to trust that
the health care system will consistently serve one's special needs. This is one reason why the
freedom to choose one's own provider is such an important component of INDIVIDUAL
CHOICE for many people.
There will be inevitable strains on this provider-patient relationship in the new health care
system, just as there are now in our current system. With proper attention to its importance,
however, this relationship can be preserved and strengthened. Breaking the link beteween
employment and individuals' health insurance plan will eliminate the severing of valued
provider-patient relationships that now often follows changes or loss of employment or changes
in the plans offered by one's employer. Managed care plans that limit members' to use of
participating physicians can still provide choice from among large panels of primary care and
specialist physicians and other providers. Several other features of the new system that we have
discussed in this section can provide further security to the provider-patient relationship. Proper
attention to protecting PROFESSIONAL INTEGRITY both against unwarranted undertreatment
from cost containment pressures and against unwarranted overtreatment from unethical
entrepreneurial conflicts of interest of providers can together strengthen professionals'
commitments to their patients. New reliance on global budgets to control costs can reduce current
intrusions into provider-patient relationships from current attempts by insurers and other
third-party payers to micro manage the clinical care of patients. Reduction of administrative
complexity can free providers from endless paperwork and enable them to renew their focus on
caring for their patients. Increased information about effectiveness of treatments from outcomes
research together with improved means of providing that information to patients in usable form
can enable patients to take a new, more active role in shared decision making with their providers
about their own care. The protection of provider-patient relationships requires continuous
vigilance in any health care system, but many features of the new system should strengthen, not
weaken, this relationship.
PROTECTING PATIENTS IN THE NEW SYSTEM
Fundamental reforms of the major social and economic institutions that make up the
health care system will inevitably bring uncertainties and conflicts about patients' and
professionals' new roles, responsibilities, and legitimate expectations in the new system. New
efforts to control the growth of health care costs will result in pressures throughout the system
to change ineffective and inefficient practices. Ensuring FAIR PROCEDURES will be especially
important in protecting the patients whom the system should be designed ultimately to serve.
Flexible and effective procedures must be designed and implemented for receiving and handling
misunderstandings, disagreements, and disputes, whether through alternative dispute resolution
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mechanisms (especially mediation and facilitation) at the Health Alliance and Health Plan levels,
through tort reform, or in the courts.
Fair procedures are necessary at the local level that are responsive to the interests and
viewpoints of the parties receiving and delivering care. For example, these procedures should
involve mechanisms that promote patient involvement in decision making and that address
disputes and conflicts when they arise. Both Health Alliances and Health Plans must identify the
procedures and individuals with authority to make final decisions, as well means for appealing
those decisions not accepted to a higher authority, as appropriate. At the national level, health
care reform demands serious review of current malpractice issues and their effect on:
patient/provider relationships, deterring negligent practice, compensating for injuries sustained,
and overall costs to the system.
Individuals, health care institutions and society at large are accustomed to handling
conflicts and disputes in adversarial and polarized ways. An important measure of quality in the
new system at all levels will be its success in preventing unnecessary problems arising from poor
communication, inattention to the needs and interests of patients and providers, and an insensitive
bureaucracy. Training in effective communication and dispute resolution will reduce the number
of misunderstandings that escalate into full-blown disputes. FAIR PROCEDURES and
INDIVIDUAL CHOICE are often best served by a system that emphasizes decisions by the
parties themselves. For example, negotiation and mediation focus on the needs of the people
directly involved, whereas decisions by higher authorities tend to stress rights and fault, and
tactics which often erode ongoing relationships between patient and provider.
FEDERAL-STATE DIVISION OF RESPONSIBILITIES
Traditionally, our states have been thought of as labs for social experiments. They can
adjust for regional differences, are closer than the federal government to the people served, and
so can provide local democratic control of social programs. This is a quite appropriate role for
the states in the new health care system so long as federal flexibility does not facilitate erosion
of equity and quality at the state level. As the body that acts for us as a nation, the federal
government bears the ultimate responsibility for ensuring that the new system lives up to all of
its guiding moral principles and values.
Federal flexibility is morally and politically justified only if the states and all Health
Alliances and Health Plans are strictly accountable for their performance. The federal government
must articulate clear and precise operational criteria of equity, quality, and fair procedures so that
specific failures of states, Health Alliances, or Health Plans, can be identified and rectified. The
challenge is to do so without being unduly clinically intrusive or adding unnecessary
administrative burdens and costs to the system. The federal government must be specifically
responsible for ensuring interstate equity between health plans. And the federal government has
a special responsibility to guard the health interests of the poor, the chronically ill, the disabled,
minorities, and other special populations whose needs have not been adequately met by our health
care system in the past. The general balance that must be maintained is between the flexibility
a dynamic and evolving health care system needs to be creative in managing care and costs more
effectively, and the accountability to ensure that all health plans and health care meet the
standards of equity and quality that best express what we collectively judge a just and caring
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society ought to be.
�TAB IB
�SECTION 1.
FOR THE PUBLIC
�April 1,1993
Ira Magaziner
Senior Advisor for Policy Development
The White House
Dear Ira:
The Preamble, I take it, has two purposes, relating to two audiences. The first
audience is policy-makers and legislators, who might seek guidancefrommoral
principles that should shape their work and identify moral parameters for the
design of the system. The second audience is the wider American public which
needs to have some sense, in your words, that this health care reform is a noble
undertaking.
Two versions of the Preamble have emergedfromthe membership of Group
17, directed to these different purposes. The two versions do not differ much in
substance. They also generally share thefirstseveral pages, except for some minor
changes in rhetoric. The first several pages were largely written by those who had in
mind the second purpose. Butfromthat point on, the second version (with the de
Tocqueville quote as a foreword) departsfromthe format of the policy-oriented list
of fifteen principles to create a document that might prove potentially useful in the
public arena.
I am therefore forwarding to you this alternative draft for your consideration
at the Tollgate. I look forward to the discussion this Sunday.
Working Group #17 - Ethics
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Group #17, April 1,1993
Preamble
A New Health Care System
"When an American asks for cooperation from his fellow citizens, it is seldom
refused. J have often seen it spontaneously given with great good will. ... If a great
and sudden calamity befalls a family, the purses of a thousand strangers are at once
willingly opened and small but numerous donations pour in to relieve their
distress.
This does not contradict individualism. Equality ... makes people feel their
independence and shows them their own weakness. They are free, but exposed to a
thousand accidents. Experience quickly teaches them that although they do not
routinely require the assistance of others, a time almost always comes when they
cannot do without it. [A] covenant exists ... between all the citizens of a democracy
when they all feel themselves subject to the same weakness and the same dangers;
their interests as well as their compassion makes it a rule with them to lend one
another assistance when required."
Alexis de Tocqueville, 1840
Preliminary Staff Working Paper - For Illustrative Purposes Only
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Group #17, April 1,1993
2
Our Common Stake
The health of a nation is a measure of its greatness. Preventable diseases, untreated
illness, and neglected disabilities tear at the fabric of a society. Access to health care
by no means guarantees health, but it helps. A nation draws together, its people
more secure, when they know that every member of the community has access,
when needed, to quality health care they can all afford. The time has come for the
richest nation on earth to ensure that all who live within its borders know that they
have ready access to good health care.
A good health care system responds to our most pressing needs. It keeps expectant
mothers healthy, assists in the safe delivery of our babies, prevents polio and
measles, repairs children's broken bones, teaches us about healthy habits, treats
diseased hearts, eases the agony of arthritis, counsels the emotionally disturbed,
provides wheelchairs for those who cannot walk and care for those who cannot
leave their homes, and comforts the dying.
Our lives change and our health care needs shift over time. We movefromthe
dependence of childhood through the pressures of adolescence and on to the stresses
and responsibilities of adulthood andfinallyto the aches, pains and wisdom of old
age. Our lives are unpredictable. We change our careers; jobs do not work out as we
had hoped; we movefromplace to place; we marry and have children, families
break up, accidents and diseases strike unexpectedly. Our well being and sense of
security depend upon a health care system that spans the discontinuities in our
lives.
Preliminary Staff Working Paper - For Illustrative Purposes Only
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Most of us will be caregivers and be cared for. At times we are properly called to
help others who need our aid. At other times we need the support of those who
can help us. Given the complexity and cost of modem health care and the
unpredictability of personal need, we cannot do this alone. Government must help
us help each other in providing health care.
No one may be left out. A fair system must work for those who speak different
languages or follow different cultural traditions. It must reach to those who live on
farms, in towns, in suburbs or dties. It must look with equal favor upon the rich
and the poor. None should be denied the care they need. No one shouldfindtheir
opportunities limited for want of health care. We must remember that those in
need are our loved ones, our neighbors, our employees, our taxpayers, our future
care-givers and ourselves.
When people are excluded from health care, they suffer a triple deprivation-the
misery of illness, the desperation of no treatment and the cruel proof that they do
not really belong. They become strangers in their own land.
When individuals lack care, the promise of our common life together is
diminished. In relieving private distress the nation also enables its people to
contribute to the common good. A health care system is important not only to each
of us individually but to the collective well-being of the American people.
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The Case for Refonn
There is much about our health care system that we should be proud of and
conserve. It has enlisted the devotion of millions of health care professionals,
created splendid hospitals, clinics and research institutions, dazzled the world with
its achievements while empowering patients to make choices in their health care.
Any reform of our system must preserve its virtues.
But our health care system is itself unhealthy. It fails to reach many of us and in so
doing fails to provide the security that a comprehensive system would. It does not
offer sufficient primary, preventative, mental health and long-term care. It supplies
too many spedalists and not enough generalists; it pays for procedures performed
rather than good outcomes achieved; it often over-treats, yet insurance coverage
sometimes disappears when most needed. It exposes people who have lost their
jobs to financial ruin. It burdens health care practitioners with too many
regulations and forms. It artifidally pits generation against generation in the
competition for resources when in fact we are bound by love with those younger
and older than ourselves. We must remove these burdens, fears and divisions
from the people of our nation.
Our system also costs more to operate than any other health care system in the
world; right now it consumes one seventh of everything we make or do. The costs
of the current system continue to spiral out of control. But, these facts, harsh as they
are, do not fully measure the real cost of the current system. The "fringe benefit" of
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health care is anything but afringecost of producing cars, computers and
refrigerators. In some industries, health care is the largest source of cost after wages
and salaries. The staggering cost of health care reduces the competitiveness of
American businesses. The draining of our economic resources into the current
health care system imperils the viability of our sodety. For our own sake, and the
sake of our children, we must be more responsible stewards of our nation's
resources.
THE MORAL IDEALS JUSTIFYING HEALTH CARE REFORM
Because major health care reform profoundly affects the lives of all Americans, it
must rest upon the moral ideals to which we are dedicated as a nation. Our longheld beliefs and our highest aspirations about community, equality, justice, and
liberty justify so grand an undertaking.
COMMUNITY
We began our life as a nation with the prodamation "We the people." Later, we
tested and affirmed that dedaration through the bitter ordeal of the Civil War. Our
sense of "we the people" has continued to expand throughout our history to indude
people of all nationalities and religions, women, and those with disabilities. The
test continues to this day. We cannot stand divided between the sick and the well,
the protected and the uninsured. Our flourishing as a people rests upon our ability
to create a health care system that binds us together as one community.
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At the time of the American Revolution, a commonly invoked moral ideal was
"public virtue" - the readiness to sacrifice self-interest for the community. When
called upon, we have shown a readiness to make such sacrifices when we are
convinced that they will fall upon us fairly the resources which these sacrifices
make possible will be expended wisely. In our own time, the need for health care
reform calls us to renew our commitment to the good of our community.
EQUALITY
As a nation we began by dedicating ourselves to the proposition that "all men are
created equal." We have slowly come to understand the importance of expanding
the moral reach of that principle to all.
Throughout our history, Americans have sought equality of opportunity. Health
care provides a way to secure equal opportunity, to redress the imbalances of birth,
fate and luck. All deserve a fair chance to succeed, to make something of
themselves; health care provides us with one of the means of living out that ideal.
However, the principle of equality need not applyrigorouslyto the distribution of
everything, but it must to health care. Defending the nation and housing its people,
along with health care, are fundamental social goods. We wouldfindit absurd to
limit the protection of defense only to those who could afford a private army. We
ought not limit access to doctors and hospitals simply to those who can afford them.
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Health care, like housing, is important. We attempt (imperfectly) to satisfy the basic
need for shelter through public housing and through tax breaks for homeowners.
We think of more lavish housing as an optional commodity. All should be housed,
but not everyone requires a mansion to satisfy the basic need for shelter. However,
an expensive treatment may be a matter of life or death for a patient. It should not
be denied solely on the grounds of inability to pay. Our long-standing reverence for
life and our commitment to equality require that health care depend on need, not
money.
JUSTICE
We believe in the principle of justice for all. Justice requires fair procedures, but it
means much more. Justice also means the fair sharing of benefits and burdens. The
just sharing of benefits requires equality of access to health care on the basis of need.
It also means sharing fairly the burdens of supporting a health care system.
Justice demands that we conserve our resources for valuable activities other than
fighting illness and pain. Our religious and secular traditions recognize the
importance of responsible stewardship of resources. We cannot spend on
everything we might want. Concern about costs, about managing efficiently and
allocating wisely, grow out of our moral convictions, not just economic necessity.
LIBERTY
Our revolution began with a protest against overbearing governmental authority.
And our Constitution enshrines the value of personal choice and tolerance of
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diversity. Health care, or the lack of it, affects individuals and families so fatefully
that we must conserve choice in our health care system. However, liberty for
Americans has meant more than simply freedomfrominterference and coercion. It
has also meant enabling our people to have the means to make choices. Equality of
access undergirds liberty; if people do not have access, they are not free.
In our generation, as we have widely expanded the liberty of people of both genders
and all ethnic backgrounds to be eligible for jobs, schools, and housing, we also
recognize we must limit our liberty to some extent so that we can enjoy the benefits
of community.
THE MORAL VALUES AND PRINCIPLES SHAPING
THE NEW HEALTH CARE SYSTEM
Our long-held beliefs of community, equality, justice, and liberty cannot directly
determine the details of health reform. However, they £an serve as the anchor for
those values and principles we use to take the measure of the current system, guide
reforms, and evaluate future performance.
Community Caring for All
Health care ranks among the necessities of life, not the accessories. It is not an
optional commodity, like a Walkman, a tie, or a scarf. It is a fundamental good.
Because health care is fundamental, it must honor and reflect the following moral
principles.
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Universal in that benefits reach all of us withoutfinancialor other barriers. No one
should fear that a change or loss of a job, part-time or temporary employment, or
economic plight will block them offfromhealth care coverage. No one should lose
access to health insurance due to pre-existing conditions, age, race, or genetic
background. The barriers to access arisingfromlinguistic and cultural differences,
geographical distance, and disability must also come down. The principle of
universal access goes to the soul of reform. It can no longer be a distant ideal; we
must offer it with all deliberate speed.
Comprehensive in that benefits meet the full range of health care needs. We
should offer primary, preventive, and long-term care, as well as acute care; home, as
well as hospital care; treatment for mental, as well as physical illness. An observer
saw through our lopsided allocations when he wrote, "Our system's philosophy
might be condensed in the motto, ^Millions for [acute] care and not one cent for
prevention!"' Those lines were written in 1886. When we attend too little to
primary, preventive, and mental health care, the cost of acute care increases: we
mistarget funds; and we fail to empower people to take responsibility for their own
health.
Fair, in that the system does not create two tiers among dtizens, dividing the nation
over this fundamental good, and fair in that the uneven costs and burdens of
meeting our health care needs spread across the entire community. Justice requires
that costs and burdens should be based on the ability to pay. The astronomical costs
of some acute and long-term services can impoverish the sick and the disabled and
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their families; and they imperil the sense of security of those of us who have not yet
been stricken. A fair sharing of benefits and burdens draws the community together
and ties the generations to one another.
Of good quality in that health care is too fundamental a good not to be good. Quality
requires providing health care professionals with an environment that fosters their
best work, protects the integrity of professional judgment, delivers effective
treatments, and weeds out the unethical and incompetent practitioner. Health care
is too fundamental a good not to get better. Therefore, the system must also support
research on the full range of health care services, including research on the
outcomes of health care. Without the assurance of quality in the basic health care
package, the well-to-do will buy up and out, returning the country to a two-nation
health care system.
Responsive to choice in that we have a large measure of freedom to choose our
doctors, the treatments we receive, and the health care plans in which we receive
them. Honoring choice in the health care system not only respects liberty; it also
engages the patient in the success of preventive, acute, rehabilitative and long-term
care.
Making the System Work
Because health care is not the only social good, it must also honor and respect the
following principles.
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Allocating Wisely. In addition to providing for health care, we must also defend the
nation, provide housing, and educate our children. Therefore, the health care
system must enable us wisely to compare and balance what we spend on health care
against other national priorities. In the past, the structure and funding of the health
care system has not permitted us to make dear choices among these priorities. By
limiting national health care expenditures, we will be in a better position to meet all
our other sodal needs. Our health care system must also enable us to evaluate and
choose among diverse health services.
Managing Efficiently is a moral, not just economic, imperative. The health care
system should be simply organized, easy for patients and professionals to use, and it
should minimize administrative cost. Effidency, though, must be defined with a
wise heart, not just a calculator. Cost controls require distinctions between needs
and wants, effectiveness and futility, and must establish some priorities among
health needs. Providers should not be bound by medical cookbooks but should be
encouraged to adopt wise treatment guidelines. Effidency in the service of
universal access is a virtue, not a limit. It can offer choices and opportunities for
health care for all people, instead of denying any choice to millions. We must
allocate our resources wisely so that we can achieve all of the goals of our health
care system.
Under the conditions of limits and scardty, justice demands wise allocation and
prudent management of resources.
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Encouraging Responsibility. Givers as well as receivers of care can make or break
the most ingenious of systems. All of us must take responsibility for the success of
our health care system in reaching its goal of improving the nation's health.
Professionals need to befreedto operate responsibly, in party by relieving them of
intrusive administrative burdens. The system must protect the integrity of
professional/patient relationships while ensuring that the profession fulfills its
public responsibilities. A huge social investment has helped to form and educate
professionals - public outlays for research and medical education, foundation gifts,
corporate grants, bonds floated to build hospitals. A good health care system needs
to foster ways in which those who have received much can give back; it must also
provide opportunities for national service or work in underserved areas. The
health care system needs healers who seek to serve the common good through their
art, who see their profession as a calling, not just a career.
The success of the health care system also depends upon the habits of the heart of
our citizenry. Patients are active partners in their health care. Preventing the heart
attack, rehabilitating from the spinal injury, coping with the stroke often require
changes in the patients* habits to succeed. The system cannot gratify all wants, tamp
down all worries, or remove the mark of mortality from our frame. We need some
self control over our wants, composure in the midst of illness, and courage in the
face of dying. No system of itself can bring these virtues to us. We need to bring
them to the system so that its benefits may sustain us more fully.
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The ancient Romans tended to emphasize the benefits of citizenship, the Athenians
emphasized its responsibilities. For its moral success, our new system of health care
requires both.
Fair Procedures. The moral ideals that shape our tradition have never coexisted in
easy tranquility. They often reinforce one another, but also conflict with one
another.
The values and principles that more immediately characterize our health care
reform will also compete and press against another for priority. These conflicts do
not discredit the principles. They help us identify what is ethically at stake, the
moral trade offs we must make.
To protect these values and principles, fair and democratic procedures should exist
for making decisions about the operation of the health care system and for resolving
disputes about individual patient care.
Even in a caring community, reasonable people will disagree about how to translate
our moral ideals, values, and principles into a well-functioning health care system.
Difficult decisions will have to be made. We are a democracy that respects the value
of all people and everyone must have access to the reasons for the decisions that
affect them so fundamentally and must have a fair procedure for resolving disputes.
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A Time To Act
We cannot treat health care reform as a partisan or ideological issue. Our founders
assumed that if a nation could create a common good it should make that good
common. We can deliver health care to all our people, and this health care will
secure and enhance life, liberty and welfare that is our nation's promisetoits
dtizens. Health care reform asks us to dedare our nation a community. Americans
see the need for this redefinition and commitment. This commitment must reflert
our national and personal values; it must recognize our interdependence; it must
embody our care for those we love and our willingness to acknowledge and accept
our neighbors help in our own hour of need. We must commit ourselves to
universal and comprehensive health care as a way to fulfill our national promise. It
is time to make that promise to each other. Healthy children, a people's health, is
our nation's covenant with its future.
"[A] covenant exists ... between all the citizens of a democracy when they all feel
themselves subject to the same weakness and the same dangers; their interests as
well as their compassion makes it a rule with them to lend one another assistance
when required."
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DRAFT
1
PREAMBLE
OUR COMMON STAKE
The way we care for each other is a measure of our nation's greatness.
Preventable diseases, untreated illness, and neglected disability tear at the fabric of our
society. Access to health care is by no means a guarantee of health, rather it signifies
our commitment to each other. Those among us who have been denied access to health
care remind us that we have fallen short of our ideals and short of what is possible. The
time has come for the richest nation on earth to ensure that all who live within its borders
are secure in the knowledge that they will have ready access to good health care.
A good health care system responds to our most pressing needs. It keeps
expectant mothers healthy, assists in the safe delivery of our babies, prevents polio and
measles, repairs children's broken bones, treats diseased hearts, eases the agony of
arthritis, counsels the emotionally disturbed, provides wheelchairs for those who cannot
walk, and comforts the dying.
As our lives change, our health care needs shift. We move from the dependence
of childhood through the ambiguities of adolescence and on to responsibilities of
adulthood and finally to the contenment and losses of old age.
Our lives are
unpredictable. We change our jobs, move from place to place; we have children,
accidents and diseases strike unexpectedly. Our well-being and sense of security
depends upon a health care system that works and spans the discontinuities of our lives.
Most of us will be caregivers and be cared for. At times we are properly called to
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splendid hospitals, clinics and research institutions, dazzled the world with its
achievements while empowering patients to make choices in their health care and in
their lives. Any reform of our system must preserve its virtues.
But, in important ways, our health care system is itself unhealthy. It fails to
reach many of us and in so doing fails to provide the security that a comprehensive
system would. It does not offer sufficient primary, preventative, mental health and
long-term care. It supplies too many specialists and not enough generalists; It pays
for procedures performed rather than good outcomes achieved; it often over-treats,
yet insurance coverage sometimes disappears when most needed. It exposes people
who have lost their jobs to financial ruin. It burdens health care practitioners with too
many regulations and forms. It artificially pits generation against generation in the
competition for resources when in fact we are bound by love with those younger and
older than ourselves. We must remove these burdens, fears and divisions from the
people of our nation.
Our system also costs more to operate than any other health care system in
the world;rightnow it consumes one seventh of everything we make or do. The costs
of the current system continue to spiral out of control. But, these facts, as harsh as
they are, do not fully measure the real cost of the current system. The fringe benefit'
of health care is anything but a fringe cost of producing cars, computers and
refrigerators. In some industries, health care is the largest source of cost after wages
and salaries. The staggering cost of health care reduces the competitiveness of
PRELIMINARY STAFF WORKING PAPER FOR ILLUSTRATIVE PURPOSES ONLY
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convinced that they will fall upon us fairly and that the resources which these
sacrifices make possible will be expended wisely. In our own time, the need for health
care reform calls us to renew our commitment to the good of our community.
Equality
As a nation we began by dedicating ourselves to the proposition that "all men
are created equal". We have come to understand the importance of expanding the
moral reach to all. Over the decades, we have come to understand that each
individual, regardless of birth, luck, and fate, deserves equal respect and should be
accorded equal dignity. Our long-standing reverence for the dignity of individuals and
our commitment to equality require that health care depend on need, not money.
The ideal of equality applies to protection from disease, disability, and suffering
just as it applies to the protection from crime, fire, and other disasters. We would find
it absurd to limit these protections solely to those who could afford insurance against
them. Similarly, access to health care ought not to depend upon a person's income,
employment, or insurance. An expensive treatment may be a matter of life or death
for a patient and should not be denied solely on the grounds of ability to pay.
Justice
Our nation was founded upon the belief that all individuals deserve a fair
chance to pursue their chosen goals in life. By providing the benefits of health care to
all, we move toward the attainment of that ideal. When we are in pain, when we
suffer from untreated illness, when we are consumed with the fight against disease,
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THE MORAL VALUES AND PRINCIPLES SHAPING THE NEW HEALTH CARE
SYSTEM
The moral values and principles shaping our health care system must reflect
and honor our long held beliefs as a nation about community, equality, justice, and
liberty. These beliefs cannot directly determine the details of health reform, but
anchor them in the moral traditions we share as a nation. Conflicts among these
values and principles arise in designing the new health care system. The values and
principles will help us recognize the tradeoffs involved in decisions about the design of
the system. They will also help us critique the current system, guide reforms, and
evaluate future performance.
Health care is of fundamental moral importance to us because it protects the
opportunities open to us to pursue our goals in life, reduces our pain and suffering,
prevents premature loss of life, and gives us information we need to pursue our lives.
COMMUNITY CARING FOR ALL
Because health care is fundamental, the moral ideals of community and
equality require that the health care system be universal, comprehensive, and
equitable in the sharing of benefits and costs.
UNIVERSAL ACCESS: Everyone must have entry into the health care system without
financial or other barriers.
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The system must not create two tiers among citizens, dividing the nation over
these fundamental services. Ability to pay should not give some people access to
important medical services that others cannot afford. Health care differs from other
important goods like housing. Modest housing will suffice for shelter, but inadequate
health care services can profoundly limit our opportunities and even cost us our lives.
SHARING COSTS FAIRLY: We should spread the uneven costs and burdens of
meeting our health care needs across the entire community; our payments for health
care should be based on our ability to pay.
The astronomical costs of some acute and long-term services can impoverish
the sick and the disabled and their families. They imperil the sense of security of those
of us who have not yet been stricken. How likely we are to be sick or to stay well
should not determine how much we must pay for health care.
We pay for health care in various ways — through taxes, insurance premiums,
and copayments for services — and these should be based on people's ability to pay.
A fair sharing of burdens can draw the community together.
GENERATIONS STANDING TOGETHER: The health care system must respond to
our needs at each stage of our lives, and we must share its benefits and burdens
fairly across generations.
We have a common stake in meeting our needs as they change throughout our
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choices.
Our new system must strive to eliminate waste and deliver services efficiently,
but we must not allow it to compromise the high quality we expect when our health is
at stake. Assuring quality requires an environment that fosters health care
professionals' best work and weeds out the unethical and incompetent practitioner.
MANAGING EFFICIENTLY: The health care system should be simply organized,
easy to use for patients and professionals, and should minimize administrative costs.
Managing efficiently is a moral, not just an economic imperative. Efficiency must
be defined with a wise heart, not just a calculator. We must reduce the cumbersome
administrative burdens on providers and patients; they interfere with quality care and
divert resources from the delivery of effective services.
CHOICE AND RESPONSIBILITY
INDIVIDUAL CHOICE: The health care system should enable all of us to make
effective choices about our providers, health care plans, and the treatments we
receive.
Health care affects individuals and their families too fatefully not to build
effective choice into the system. The system must provide us with adequate
information
and counsel to let us make informed choices. Honoring choice in the health care
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democratic procedures should exist for making decisions about the operation of the
health care system and for resolving disputes about individual patient care.
Even in a caring community, reasonable people will disagree about how to
translate our moral ideals, values, and principles into a well-functioning health care
system. Difficult decisions will have to be made. We are a democracy that respects
the value of all people and everyone must have access to the reasons for the
decisions that affect them so fundamentally and must have a fair procedure for
resolving disputes.
Conflicts between these convictions may well arise but they help us identify
what is at stake morally as we design health care system, implement reform and
evaluate future performance.
A TIME TO ACT
We cannot treat health care reform as a partisan or ideological issue. Our
founders assumed that if a nation could create a common good it should make that
good common. We can deliver health care to all our people, and this health care will
secure and enhance life, liberty, and welfare that is our nation's promise to its citizens.
Health care reform asks us to declare our nation a community. Americans see the
need for this redefinition and commitment. This commitment must reflect our national
and personal values; it must recognize our interdependence; it must embody our care
for those we love and our willingness to acknowledge and accept our neighbor's help
PRELIMINARY STAFF WORKING PAPER FOR ILLUSTRATIVE PURPOSES ONLY
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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Health Care Reform
Identifier
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2006-0810-F
Description
An account of the resource
<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
Provenance
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Clinton Presidential Records
Publisher
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William J. Clinton Presidential Library & Museum
Text
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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Ethical Foundations Briefing Book [1]
Creator
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Health Care Task Force
General Files
Identifier
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2006-0810-F Segment 1
Is Part Of
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Box 47
<a href="http://clinton.presidentiallibraries.us/items/show/36144" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12090749" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Preservation-Reproduction-Reference
Date Created
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5/5/2015
Source
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42-t-2194630-20060810F-Seg1-047-004-2015
12090749